I contacted Dr. Peter Millett who is a shoulder specialist and the director of shoulder surgery at the Steadman Hawkins Clinic in Vail, Colorado. He was kind enough to answer some questions about shoulder separations, as they might pertain to the 49ers' quarterback:

Question: Is a grade-3 shoulder separation rare among athletes? (Smith sustained his when a 308-pound lineman landed on him with all his weight).

Dr. Millett: It's not rare but, in fact, fairly common, particularly in contact sports, such as football and ice hockey and in sports such as cycling, skiing and snowboarding, where athletes fall onto their shoulders or suffer collisions.

Q: What determines whether an athlete requires surgery or not after a grade-3 separation?

Dr. Millett: Usually the severity of the symptoms.

Q: So there are varying degrees of grade-3 separations?

Dr. Millett: Well, there are varying degrees in which patients are affected by grade-3 AC separations. About 70-80 percent of folks do well and 20-30 percent are significantly bothered by the separation.

Q: What are the advantages of surgery? Disadvantages?

Dr. Millett: The advantages are it restores the alignment of the clavicle and the appearance and function of the shoulder. The disadvantages are the usual risks of undergoing surgery, the recovery that is needed, and the risk of recurrent injury or separation to the AC joint.

Q: Do the AC and CC ligaments reattach on their own without surgery?

Dr. Millett: Not typically in grade 3. The patients learn to live with the deformity.

Q: If the ligaments do not reattach without surgery, does this cause problems?

Dr. Millett: Sometimes, the instability of the end of the clavicle is bothersome in some individuals, such as in overhead athletes, laborers, electricians, etc. That being said, it is still usually worth a trial of non-operative conservative treatment as the majority will do well without surgery and delaying surgery does not change the outcome of the surgery.

Q: What kind of role does swelling play in the timeframe for recovery?

Dr. Millett: Swelling is uncomfortable and inhibits muscle activity. Once this resolves, one can usually start to move the shoulder again. It takes 7-14 days for the injury swelling to resolve.

Q: If an athlete, such as a quarterback, does not have surgery, generally how long does it take for him to be able to play again?

Dr. Millett: For a grade 3, it really varies. The return can be in as little time as two weeks or it may take two months, although in some instances there are athletes who remain unable to return because their injury severely impacts their performance. In these instances, the athletes usually end up having surgery to fix the shoulder. For example, I just spoke with one of my patients who is a high level collegiate wide receiver. He had a grade 3 AC separation and was unable to perform at the level he needed to. We discussed the options and he decided to have surgery. Last year, he was a unanimous Academic and Athletic All-American and he led the league in receptions!

Q: If an athlete opts for surgery, how long is the recovery time?

Dr. Millett: Four to six months, typically. Maybe up to eight months for a throwing athlete who needs power and precision.

Q: Is a person more susceptible to sustain separated shoulders in the future after this has happened once?

Dr. Millett: Once it is separated, it remains separated until it is fixed surgically.

Q: If the shoulder remains separated without surgery, would you generally recommend surgery for an athlete that must use that throwing arm?

Dr. Millett: If the athlete is symptomatic or if one's performance is limited and they have tried non-operative treatment for at least 6-12 weeks. It is a tough call. Some folks are simply not happy with the deformity and pain and decide early on to get it fixed. Another example is Brian Griese who had this injury a few years ago. After trying to go without surgery, he ended up having his shoulder fixed and is now back to playing in the NFL.

Q: Is there any risk that an athlete will not regain full strength in his shoulder after a grade-3 separation?

Dr. Millett: Yes, but it is rare.

Q: Is there anything else you believe is pertinent information that people should know?

Dr. Millett: There are some exciting new techniques being developed by myself and others that can be used to fix AC separations arthroscopically. This approach is less invasive, less painful, and may hasten the recovery for athletes.

* * *

Thanks again to Dr. Peter Millett. Please click here to for more information or to check out his Web site.

* * *